Functional evaluations for pulmonary resection for lung cancer in octogenarians. Investigation from postoperative complications

Surgery for Metastatic Spinal Disease in Octogenarians and Above: Analysis of 78 Patients

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Octogenarians living with spinal metastases are a challenging population to treat. Our objective was to identify the rate, types, management, and predictors of complications and survival in octogenarians following surgery for spinal metastases.

METHODS

A retrospective review of a prospectively collected cohort of patients aged 80 years or older who underwent surgery for metastatic spinal tumor treatment between 2008 and 2019 were included. Demographic, intraoperative, complications, and postoperative follow-up data was collected. Cox proportional hazards regression and logistic regression were used to associate variables with overall survival and postoperative complications, respectively.

RESULTS

78 patients (mean 83.6 years) met inclusion criteria. Average operative time and blood loss were 157 minutes and 615 mL, respectively. The median length of stay was 7 days. The overall complication rate was 31% (N = 24), with 21% considered major and 7% considered life-threatening or fatal. Blood loss was significantly associated with postoperative complications (OR = 1.002; P = 0.02) and mortality (HR = 1.0007; P = 0.04). Significant associations of increased risk of death were also noted with surgeries with decompression, and cervical/cervicothoracic index level of disease. For deceased patients, median time to death was 4.5 months. For living patients, median follow-up was 14.5 months. The Kaplan-Meier based median overall survival for the cohort was 11.6 months (95% CI: 6.2-19.1).

CONCLUSIONS

In octogenarians undergoing surgery with instrumentation for spinal metastases, the median overall survival is 11.6 months. There is an increased complication rate, but only 7% are life-threatening or fatal. Patients are at increased risk for complications and mortality particularly when performing decompression with stabilization, with increasing intraoperative blood loss, and with cervical/cervicothoracic tumors.

Sentinel node sampling limits lymphadenectomy in stage I non-small cell lung cancer

OBJECTIVE

It is controversial whether a systematic mediastinal lymph node dissection (MLND) needs to be performed in all patients with stage I lung cancer. The present study was done to examine the new sentinel lymph nodes hypothesis based on the lobe of the primary tumor.

METHODS

In our first study, the lymph node (LN) metastases were assessed in 291 stage I non-small cell lung cancer (NSCLC) patients who had a major lung resection with a systematic mediastinal lymph node dissection. We evaluated the validity of using our new sentinel lymph nodes method based on the lobe of the primary tumor as follows: the pretracheal (#3), tracheobronchial (#4), and hilar nodes (#10) for right upper lobe tumors; #4, subcarinal (#7), and #10 for middle lobe tumors; the subaortic (#5), paraaortic (#6), and #10 for left upper lobe tumors; and the #7, #10, and interlobar nodes (#11) for tumors in either lower lobes. In the second study, we performed a lobectomy with new sentinel node sampling in 64 patients with preoperative complications. If all of the sampling nodes showed no metastases on frozen section diagnosis, systematic node dissections were not performed.

RESULTS

Six of 291 patients in the first study had skip metastases that did not involve the new sentinel nodes; 5 of the 6 patients had macroscopic pleural invasion. Thus, we defined pleural invasion as an exclusion criterion for the second study. In the second study, the median follow-up time was 39 months. Metastatic lymph nodes were detected in 11 of 64 patients. Fifty-three patients (83%) had no metastasis in the sampled nodes, and, therefore, a mediastinal lymph node dissection was not done. The morbidity rate in the sampling group was 36%, and there was no mortality. In the sampling group, local recurrences were observed in two patients, distant metastases in eight, and carcinomatous pleuritis in one; the overall 5-year survival rate was 82%.

CONCLUSIONS

We found that it is possible to perform a less invasive lymphadenectomy for patients with stage I lung cancer using intra-operative sampling of new sentinel lymph nodes.

Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell lung cancer

OBJECTIVE

We conducted this study to evaluate the surgical invasiveness and the safety of video-assisted thoracic surgery lobectomy for stage I lung cancer.

METHODS

Video-assisted thoracic surgery lobectomies were performed on 43 patients with clinical stage IA non-small cell lung cancer. We compared the surgical invasiveness parameters with 42 patients who underwent lobectomy by conventional thoracotomy.

RESULTS

Intraoperative blood loss was significantly less than that in the conventional thoracotomy group (151+/-149 vs. 362+/-321 g, p<0.01). Chest tube duration (3.0+/-2.1 vs. 3.9+/-1.9 days) was significantly shorter than those in the conventional thoracotomy group (p<0.05). The visual analog scale which was evaluated as postoperative pain level on postoperative day 7, maximum white blood count and C-reactive protein level were significantly lower than those in the conventional thoracotomy group (p<0.05). The morbidity rate was significantly lower than that in the conventional thoracotomy group (25.6% vs. 47.6%, p<0.05). Sputum retention and arrhythmia were significantly less frequent than in the conventional thoracotomy group (p<0.05). We experienced no operative deaths in both groups.

CONCLUSION

We conclude that video-assisted thoracic surgery lobectomy for stage I non-small cell lung cancer patients is a less invasive and safer procedure with a lower morbidity rate compared with lobectomy by thoracotomy.

Impact of mediastinal lymph node dissection on octogenarians with non-small cell lung cancer

OBJECTIVE

Impacts of mediastinal lymph node dissection on a patient's course after pulmonary resection is unclear in octogenarians with non-small cell lung cancer.

METHODS

Retrospectively identified subjects included 39 octogenarians and 1 nonagenarian, with grades according to the Charlson Comorbidity Index ranging from only 0 to 2. We performed mediastinal lymph node dissection in 19 patients (D group), and just lymph node sampling biopsy in the other 21 (S group). We compared clinicopathologic features and outcome after surgery between both groups.

RESULTS

Deterioration of performance status at the time of discharge, evident in 17 patients overall, was significantly more frequent in the D group. Postoperative complications occurred in 27 patients overall and there was no significant difference between the two groups. Survival rates in younger patients at 1, 3, and 5 years were 86, 59, and 49%, respectively; in octogenarians these were 83, 58, and 42% (no significant difference). Nor did survival differ significantly by surgical management of mediastinal lymph nodes; 1-, 3-, and 5-year survival rates were 94, 63, and 40%, respectively in the D group and 78, 66, and 43%, respectively in the S group.

CONCLUSION

Octogenarians with non-small cell lung cancer should be treated by urgent pulmonary resection whenever possible. Since mediastinal lymph node dissection has little effect on long-term survival or the carried risk of worsening performance status at discharge, pulmonary resection without complete mediastinal lymph node dissection should be considered.

Surgical Treatment for Lung Cancer in Octogenarians

PURPOSE

We conducted this study in order to determine how we should perform the surgical treatment for clinical stage I non-small cell lung cancer (NSCLC) in octogenarians.

METHODS

Thirty-three octogenarians with clinical stage I NSCLC participated in this study. They were retrospectively divided into two groups: one group of 11 patients who underwent a lymph node dissection (ND group), and one group of 22 patients who did not undergo this procedure (ND0 group). We analyzed the surgical invasiveness, morbidity, mortality, and survival in both groups.

RESULTS

The morbidity rate in the ND group (45%) was higher than that in the ND0 group (23%); however, the difference was no statistically significant (P = 0.1805). There was no significant difference in the overall survival rates of the two groups (P = 0.1647), and the median survival time of the ND0 group (76 months) was slightly longer than that of the ND group (26 months). There was no significant difference in local recurrence rate between the two groups (9.1% vs 4.5%, P = 0.6059).

CONCLUSION

We thus conclude that a limited operation without lymph node dissection might be the best surgical treatment for carefully selected octogenarians with clinical stage I NSCLC.

Thoraxchirurgie im Alter

In the near future, over 40% of patients with lung cancer will be over 70 years old at the time their disease is diagnosed. Age per se, however, should not lead to the denial of a potentially curative surgical intervention. It has been shown that older patients (over 70 years), as well as patients over 80 years of age, may tolerate a lobectomy or even a pneumonectomy quite well. Most patients with lung cancer are present or former smokers and have underlying pulmonary problems, especially chronic obstructive lung disease. They are at high risk of both morbidity and mortality from surgery due to significant cardiovascular disease. The indications for surgical intervention should be based on reliable preoperative tumor staging and pulmonary assessment by an experienced interdisciplinary panel of physicians, taking into consideration the individual cardiopulmonary status of the patient. This assessment, combined with the American Society of Anesthesiologists risk classification and the overall clinical assessment by the surgeon, will provide the best available evidence for carefully weighing the benefits and risks of an operation. The responsibility for this assessment must be viewed-in the case of early stage lung cancer-in relation to the relative lack of alternative treatments for surgical intervention with comparable 5-year survival rates (>50%).

Pulmonary resection in octogenarians with stage I nonsmall cell lung cancer: a 22-year experience

BACKGROUND

Recent reports indicate that age is not a contraindication to pulmonary resection for octogenarians with nonsmall cell lung cancer (NSCLC), but other data are lacking. The purpose of this study was to determine outcomes in these patients, particularly short- and long-term survival with stage I disease.

METHODS

A retrospective cohort of 68 octogenarians with NSCLC who underwent curative resection from 1980 to 2002 was followed-up for outcomes.

RESULTS

Median age was 82 years old (range, 80-87 years old) consisting of 44 males (65%), with a mean follow-up of 32 months (range, 1-178 months). Operations included: 47 lobectomies (69%), 11 wedge resections (16%), 5 segmentectomies (8%), 4 bilobectomies (6%), and 1 pneumonectomy (1%). There were 31 adenocarcinomas (46%), 18 squamous carcinomas (26%), 12 bronchioalveolar carcinomas (18%), 4 large cell carcinomas (6%), and 3 miscellaneous malignant neoplasms (4%). Median hospital stay was 7 days (range, 3-53 days). Thirty-day mortality was 8.8% (n = 6) with 83% developing cardiopulmonary complications. Overall actuarial survival at 1, 3, and 5 years was 73%, 51%, and 34%, respectively. Of 41 patients (60%) with stage I disease, 23 were T1 lesions. Five-year survival was significantly different between stages Ia and Ib patients (61% and 10%, respectively, p = 0.001). Patients in more advanced stages had a 5-year survival of 3/27 (11%). Multivariate analysis identified advanced tumor stage, lower ASA physical status, and low FEV(1) as factors associated with poorer long-term survival.

CONCLUSIONS

The 5-year survival, particularly in patients with stage Ia tumors with favorable ASA and FEV(1), supports the notion that health status and tumor stage outweigh chronologic age in determining surgical candidates.

Preoperative assessment of the thoracic surgery patient: pulmonary function testing

Tests of pulmonary function before thoracic surgery can help to assess the risk of perioperative morbidity and mortality, and are the basis for estimating remaining lung function after resection of lung tissue. Testing has evolved over the past 50 years from reliance on the maximum breathing capacity to a range of studies including spirometry, and measurement of lung volume, diffusing capacity, and arterial blood gases, and the interpretation of these in conjunction with radionuclide scanning. The surgeon must consider both the early postoperative decrement in function and the level to which the patient is expected to recover. Although it is difficult to establish absolute limiting values, and current surgical techniques are blurring the boundary further, the reported experience underlying current guidelines is reviewed.